Delta Dental of Pennsylvania

DeltaCare? USA

Dental Health Care Program for Eligible Employees and Dependents

Combined Evidence of Coverage and Disclosure Form

STATE OF MARYLAND

MDD57

Provided by:

Delta Dental of Pennsylvania

One Delta Drive Mechanicsburg, PA 17055

Administered by:

Delta Dental Insurance Company P.O. Box 1803 Alpharetta, GA 30023 844-697-0578

statemd

In Maryland, DeltaCare? USA is underwritten by Delta Dental of 3HQQV\OYDQLDDQRWIRUSUR?WGHQWDOVHUYLFHFRPSDQ\

MDD57

V17

EVIDENCE OF COVERAGE

DISCLOSURE FORM

DeltaCare? USA Dental Health Care Program

This booklet is a Combined Evidence of Coverage and Disclosure Form ("EOC") for your DeltaCare USA Dental Health Care Program ("Program") provided by Delta Dental of Pennsylvania ("Delta Dental"). The Program has been established and is administered in accordance with the provisions of a Group Dental Service Contract ("Contract") issued by Delta Dental.

This EOC describes the provisions of the Contract between your group and 'HOWD 'HQWDO7KLV (2& SURYLGHV FRYHUDJH IRU GHQWDO VHUYLFHV DQG %HQH?WV as a Dental Plan Organization in accordance with the terms and conditions VSHFL?HGLQWKH&RQWUDFW

THE EOC CONSTITUTES ONLY A SUMMARY OF THE PROGRAM. THE CONTRACT MUST BE CONSULTED TO DETERMINE THE EXACT TERMS AND CONDITIONS OF THE COVERAGE PROVIDED UNDER IT.

A COPY OF THE CONTRACT WILL BE FURNISHED UPON REQUEST. ANY DIRECT CONFLICT BETWEEN THE CONTRACT AND THE EOC WILL BE RESOLVED ACCORDING TO THE TERMS WHICH ARE MOST FAVORABLE TO YOU. READ THIS EOC CAREFULLY AND COMPLETELY.

PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW HOW TO OBTAIN DENTAL BENEFITS.

7KHWHOHSKRQHQXPEHUZKHUH\RXPD\REWDLQLQIRUPDWLRQDERXW%HQH?WVLV 844-697-0578. Customer Service representatives are available between 8 a.m.-8 p.m. Eastern time, Monday-Friday.

MDD57

V17

Table of Contents 'H?QLWLRQV.............................................................................................................. 1 (OLJLELOLW\IRU%HQH?WV ............................................................................................. 2 Premiums .............................................................................................................. 4 How to use the DeltaCare USA Program - Choice of Contract Dentist .................................................................................. 4 %HQH?WV/LPLWDWLRQVDQG([FOXVLRQV ..................................................................... 6 Copayments and Other Charges........................................................................... 6 Emergency Services.............................................................................................. 6 Specialist Services ................................................................................................ 6 Claims for Reimbursement .................................................................................... 7 &RRUGLQDWLRQRI%HQH?WV ........................................................................................ 8 Appeal Procedure................................................................................................ 11 5HQHZDODQG7HUPLQDWLRQRI%HQH?WV .................................................................. 17 Cancellation of Enrollment................................................................................... 17 Contestability ....................................................................................................... 18 Legal Actions ....................................................................................................... 19 Optional Continuation of Coverage ..................................................................... 19 6FKHGXOH$'HVFULSWLRQRI%HQH?WVDQG&RSD\PHQWV ........................................ 23 6FKHGXOH%/LPLWDWLRQVDQG([FOXVLRQVRI%HQH?WV............................................ 36

MDD57

V17

'H?QLWLRQV

As used in this booklet:

Administrator means Delta Dental Insurance Company ("Delta Dental") or other entity designated by Delta Dental of Pennsylvania, operating as an Administrator in the state of Maryland. Certain functions described in the Contract and in this booklet may be performed by the Administrator, as designated by Delta Dental. The mailing address for the Administrator is P.O. Box 1803, Alpharetta, GA 30023. The Administrator will answer calls directed to 844-697-0578 between 8 a.m.-8 p.m. Eastern time, Monday-Friday.

Authorization means the process by which the Administrator determines if a SURFHGXUHRUWUHDWPHQWLVDUHIHUDEOH%HQH?WXQGHUWKH(QUROOHH?VSODQ

%HQH?WV mean those dental services which are provided under the terms of the Group Dental Service Contract and described in this booklet.

Contract Dentist means a Dentist who provides services in general dentistry DQGZKRKDVDJUHHGWRSURYLGH%HQH?WVWR(QUROOHHVXQGHUWKLV3URJUDP

Contract Orthodontist means a Dentist who specializes in orthodontics and ZKRKDVDJUHHGWRSURYLGH%HQH?WVWR(QUROOHHVXQGHUWKLV3URJUDP

Contract Specialist means a Dentist who provides Specialist Services and ZKRKDVDJUHHGWRSURYLGH%HQH?WVWR(QUROOHHVXQGHUWKLV3URJUDP

Copayment means the amount charged to an Enrollee by a Contract Dentist IRUWKH%HQH?WVSURYLGHGXQGHUWKLV3URJUDP

Dentist means a duly licensed Dentist legally entitled to practice dentistry at the time and in the state or jurisdiction in which services are performed.

Eligible Dependent means any dependent of an Eligible Employee who is HOLJLEOHIRU%HQH?WVDVUHFRJQL]HGE\WKH*URXSDQGRUVWDWHODZ

Eligible Employee means any employee or group member who is eligible IRU%HQH?WVDVUHFRJQL]HGE\WKH*URXSDQGRUVWDWHODZ

Emergency Services mean only those dental services immediately required for alleviation of severe pain, swelling or bleeding, or immediately required to DYRLGSODFLQJWKH(QUROOHH?VKHDOWKLQVHULRXVMHRSDUG\

Enrollee means an Eligible Employee ("Primary Enrollee") or an Eligible 'HSHQGHQW?'HSHQGHQW(QUROOHH?HQUROOHGWRUHFHLYH%HQH?WV

Group means the applicant (employer or other organization) contracting to REWDLQ%HQH?WVIRU(OLJLEOH(PSOR\HHV

MDD57

- 1 -

V17

Open Enrollment Period means the period of time during the year in which (OLJLEOH(PSOR\HHVUHWLUHHVFDQPDNHDFKDQJHLQWKHLU%HQH?WV

Optional means any alternative procedure presented by the Contract Dentist WKDWVDWLV?HVWKHVDPHGHQWDOQHHGDVDFRYHUHGSURFHGXUHLVFKRVHQE\WKH Enrollee and is subject to the limitations and exclusions of the Contract.

Out-of-Network means treatment by a Dentist who has not signed an DJUHHPHQWZLWK'HOWD'HQWDOWRSURYLGH%HQH?WVXQGHUWKHWHUPVRIWKH Contract.

Specialist Services mean services performed by a Dentist who specializes in the practice of oral surgery, endodontics, periodontics or pediatric dentistry, and which must be authorized by the Administrator.

We, Us or Our means Delta Dental or the Administrator, as appropriate.

(OLJLELOLW\IRU%HQH?WV

Eligible Employees and Eligible Dependents (includes children up to age 26) UHFHLYH%HQH?WVDVVRRQDVWKH\DUHHQUROOHGLQWKH3URJUDP

Eligible Dependents become eligible on:

1)

the date you are eligible for coverage;

2)

as soon as an Eligible Dependent becomes your dependent, or

at any time subject to a change in legal custody or lawful order to

SURYLGH%HQH?WV

The dependents of Primary Enrollees are eligible to enroll on the same date that the employee, of whom they are a dependent, becomes a Primary Enrollee. Later-acquired dependents become eligible as soon as they acquire dependent status. Coverage is also extended to any child who is recognized XQGHUD4XDOL?HG0HGLFDO&KLOG6XSSRUW2UGHU40&62,IHPSOR\HHLVQRW currently enrolled, we shall enroll both the employee and the child, without regard to enrollment period restrictions, within 20 business days of receipt of a child medical support order. If the employee is currently enrolled and a child is eligible for enrollment, we shall complete the enrollment without regard to enrollment period restrictions, within 20 business days of receipt of a child medical support order.

Coverage for a child covered by a medical support order will remain in effect unless written evidence is provided to Delta Dental that:

1)

the order is no longer in effect;

2)

the child has been, or will be, enrolled under other reasonable dental

insurance coverage that will take effect on or before the effective

date of the termination;

MDD57

- 2 -

V17

3)

the employer has eliminated dependent coverage for all of its

employees; or

4)

the Primary Enrollee is no longer eligible for coverage, except that

the Primary Enrollee may then elect continuation coverage for the

child under COBRA, if applicable.

Notwithstanding any limiting age stated in this EOC, any unmarried child FRYHUHGXQGHUWKLV(2&DVDGHSHQGHQWRIDQ(QUROOHHZKRLVFKLH?\ dependent for support upon the Enrollee, and who, at the time of reaching the limiting age, is incapable of self-support because of mental or physical LQFDSDFLW\WKDWFRPPHQFHGSULRUWRWKHFKLOG?VDWWDLQLQJWKHOLPLWLQJDJH shall continue to be covered under this EOC while remaining so dependent, unmarried, and mentally or physically incapacitated, until the coverage on the Enrollee upon whom the child is dependent terminates.

Dependents on active military duty are not eligible. No Eligible Dependent may be enrolled under more than one Eligible Employee/retiree. Medicare eligibility shall not affect the eligibility of an Eligible Employee or an Eligible Dependent.

Special Enrollment Periods - Enrollment Changes

After the effective date, you can change your enrollment during the Open Enrollment Period. There are also special enrollment periods when the Primary Enrollee may add or remove himself/herself and his/her Dependent Enrollees. These life change events include:

1)

birth of a child or grandchild;

2)

adoption of a child;

3)

court order of placement or custody of a child;

4)

loss of other coverage;

5)

marriage or other lawful union between two adults.

If you enrolled, or are eligible to enroll, a new dependent or yourself as a result of one of these events, you must supply the required enrollment change information to your Group within 60 days of the date of the life FKDQJHHYHQW7KHGHSHQGHQWPXVWPHHWWKHGH?QLWLRQRI(OLJLEOH'HSHQGHQW as determined by State of Maryland.

The Primary Enrollee may also add or remove dependents or change plans IRUWKHUHDVRQVGH?QHGE\DQGGXULQJWKHWLPHIUDPHVVSHFL?HGE\DSSOLFDEOH law or regulation.

MDD57

- 3 -

V17

Except for newborn or adopted children, coverage for the new dependent will EHJLQRQWKHGDWHVSHFL?HGLQWKHHQUROOPHQWLQIRUPDWLRQSURYLGHGWRXVDV long as the premium is paid.

Newborns of an Enrollee may be enrolled from the moment of birth. Adopted children may be enrolled from the date of adoption or placement, except for those adopted or placed within 60 days of birth who may be a Dependent Enrollee from the moment of birth. In order for coverage of QHZERUQRUDGRSWHGFKLOGUHQWRFRQWLQXHEH\RQGWKH?UVWGD\SHULRGLI additional premium is required to cover a newly enrolled dependent child, WKHFKLOG?VHQUROOPHQWLQIRUPDWLRQPXVWEHSURYLGHGWRXVDQGWKHUHTXLUHG premium must be paid. A minor for whom guardianship is granted by court or testamentary appointment may be enrolled from the date of appointment.

Dependent coverage may only be terminated when certain life change events occur including death, divorce or dissolution of the union, reaching the limiting age or during Open Enrollment Periods.

Late Enrollment

If you or your dependent(s) are not enrolled within 60 days of initial eligibility RUGXULQJWKHVSHFLDOHQUROOPHQWSHULRGVSHFL?HGIRUDOLIHFKDQJHHYHQW\RX or your dependent(s) cannot enroll until the next special enrollment period or Open Enrollment Period. If you are required by court order to provide coverage for a dependent child, you will be permitted to enroll the dependent child without regard to enrollment season restrictions.

Voluntary Disenrollment

,I\RXFKRRVHWRGURS\RXUFRYHUDJHRU\RXUGHSHQGHQW?VFRYHUDJHXQGHUWKLV Program at any time during the contract term or during the Open Enrollment Period, you will only be permitted to reenroll yourself or your dependents during a future Open Enrollment Period or upon the occurrence of a qualifying status change.

Premiums

This Program requires premiums to be paid to us. If you are required to pay all or any portion of the premiums, you will be advised of the amount prior to enrollment and it will be deducted from your earnings by payroll deduction. The Group will be responsible for sending all payments of premiums to us.

How to use the DeltaCare USA Program - Choice of Contract Dentist

To enroll in this Program, you must select a Contract Dentist for both yourself and any Dependent Enrollee from the list of Contract Dentists furnished during the enrollment process. Collectively, you and your Eligible Dependents may select no more than three Contract Dentist facilities. If you fail to select a Contract Dentist or the Contract Dentist selected becomes unavailable, the

MDD57

- 4 -

V17

Administrator will request the selection of another Contract Dentist or assign you to a Contract Dentist. You may change your assigned Contract Dentist by directing a request to the Customer Service department at 844-697-0578 between 8 a.m.-8 p.m. Eastern time, Monday-Friday. In order to ensure that \RXU&RQWUDFW'HQWLVWLVQRWL?HGDQGRXUHOLJLELOLW\OLVWVDUHFRUUHFWFKDQJHV in Contract Dentists must be requested prior to the 21st of the month for FKDQJHVWREHHIIHFWLYHWKH?UVWGD\RIWKHIROORZLQJPRQWK

Shortly after enrollment, you will receive a DeltaCare USA membership packet that tells you the effective date of your Program and the address and telephone number of your Contract Dentist. After the effective date in your PHPEHUVKLSSDFNHW\RXPD\REWDLQGHQWDOVHUYLFHVZKLFKDUH%HQH?WV 7RPDNHDQDSSRLQWPHQWVLPSO\FDOO\RXU&RQWUDFW'HQWLVW?VIDFLOLW\DQG identify yourself as a DeltaCare USA Enrollee. Initial appointments should EHVFKHGXOHGZLWKLQIRXUZHHNVXQOHVVDVSHFL?FWLPHKDVEHHQUHTXHVWHG Inquiries regarding availability of appointments and accessibility of Dentists should be directed to the Customer Service department at 844-697-0578.

EACH ENROLLEE MUST GO TO HIS OR HER ASSIGNED CONTRACT DENTIST TO OBTAIN COVERED SERVICES, EXCEPT FOR SERVICES PROVIDED BY A SPECIALIST REFERRED BY A CONTRACT DENTIST, OR FOR EMERGENCY SERVICES REQUIRED DURING NON-BUSINESS +2856:+,/(0,/(625025()5207+(&2175$&7'(17,67?6 FACILITY OR WHEN THE ENROLLEE IS UNABLE TO REACH THEIR CONTRACT DENTIST. ANY OTHER TREATMENT IS NOT COVERED UNDER THIS PROGRAM, WITH THE FOLLOWING EXCEPTION:

If, during the term of the Contract, none of the Contract Dentists can render necessary care and treatment to the Enrollee due to circumstances not reasonably within the control of Delta Dental or the Administrator, such as complete or partial destruction of facilities, war, riot, civil insurrection, labor GLVSXWHVRUWKHGLVDELOLW\RIDVLJQL?FDQWQXPEHURIWKH&RQWUDFW'HQWLVWV then the Enrollee may seek treatment from an independent licensed Dentist of his/her own choosing. The Administrator will pay the Enrollee for the expenses incurred for the dental services with the following limitations: the Administrator will pay the Enrollee for services which are listed in the 'HVFULSWLRQRI%HQH?WVDQG&RSD\PHQWV, as No Cost, to the extent that such fees are reasonable and customary for Dentists in the same geographic area; the Administrator will also pay the Enrollee for those services listed in the 'HVFULSWLRQRI%HQH?WVDQG&RSD\PHQWV for which there is a Copayment, to the extent that the reasonable and customary fees for such services exceed the Copayment for such services provided under this Program. The Enrollee may be required to give written proof of loss. Delta Dental and the Administrator agree to be subject to the jurisdiction of the Maryland Insurance Commissioner in any determination of the impossibility of providing services by Contract Dentists.

MDD57

- 5 -

V17

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download